Review

Gardner-Diamond syndrome: a systematic review of

treatment options for a rare psychodermatological disorder
Megan E. Blocka, BS , Jenna L. Sitengaa, BS, Michael Lehrerb, MD, and
Peter T. Silbersteinc, MD

a
Creighton University School of Medicine,
Omaha, NE, USA, bMayo Clinic Hospital,
Phoenix, AZ, USA, and cDivision of
Hematology/Oncology, Creighton University
School of Medicine, Omaha, NE, USA
Correspondence
Megan E. Block, BS
Creighton University School of Medicine
2500 California Plaza
Omaha, NE
USA
E-mail: meganblock@creighton.edu
Funding: None.
Conflicts of interest disclosure: None
declared.
Human and animal rights: This study does
not involve human or animal subjects
doi: 10.1111/ijd.14235
Abstract
Gardner-Diamond syndrome (GDS) is a rare psychodermatological condition characterized
by the formation of spontaneous, painful skin lesions that develop into ecchymosis
following episodes of severe physiological or psychological stress. The majority of GDS
cases occur in young adult females, and although the etiology of this rare disorder is
unknown, there appears to be a psychological component correlated with the coexistence
of previous psychiatric diagnoses. Due to the rare nature of this disorder, there exist few
guidelines for prompt clinical diagnosis and optimal treatment. Here, a systematic review
was conducted to include 45 cases of patients with GDS to better understand clinical
presentation as well as current treatment options. Ultimately, GDS is a diagnosis of
exclusion after other coagulopathies and causes of purpura are ruled out. High clinical
suspicion following laboratory and clinical exclusion of known physiological causes is
necessary for diagnosis. Selective serotonin reuptake inhibitors (SSRIs) and corticosteroids
are cost effective first line treatments for GDS with proven efficacy in symptomatic relief.
GDS refractory to initial treatment may require regular psychotherapy and titrated SSRI
dosages to achieve long-term success. This review of available case studies serves to
comprehensively describe the clinical presentation and available treatment approaches to
this rare psychodermatological disorder.

depression, anxiety, obsessive-compulsive personality disorder,

Introduction
Gardner-Diamond syndrome (GDS), also referred to as auto-
erythrocyte sensitization syndrome or psychogenic purpura, is a
rare condition characterized by the formation of spontaneous,
painful skin lesions that develop into ecchymosis following epi-
sodes of severe physiological or psychological stress. First
described in 1955 by Frank Gardner and Louis Diamond, these
lesions most commonly occur on the extremities, face, and
trunk.1 Classically, an episode is preceded by a burning or tin-
gling sensation of the skin with subsequent erythema and pruri-
tus. Within a day of the initial presentation, the ecchymotic
lesions appear and will regress over days to weeks. Other sys-
temic symptoms including nausea, fatigue, arthralgia, severe
headaches, and abdominal pain have been reported to accom-
pany the ecchymosis seen with GDS.2,3
The majority of GDS cases occur in young adolescent and
adult females. It is unknown why the condition primarily affects
women. One study proposed there may be hormonal influences,
particularly from estrogen, in the development of GDS.4
Although the etiology of this rare disorder is unknown, there
appears to be a psychological component. The disease is corre-
lated with the coexistence of psychiatric diagnoses such as
and bipolar disorder.5,6 Cases where a previous psychiatric dis-
order does not exist often have symptomatic flares following
adverse life experiences and events of extreme psychological
distress. These psychological stressors include events such as
the death of a family member, history of abuse or sexual
assault, abortions, or marital stress.7,8 The link between physio-
logical presentation and psychiatric undertones in this psycho-
dermatological disorder is clear and substantial, thus a thorough
history is important for making a diagnosis.
In addition to obtaining a thorough psychiatric history, acqui-
sition of laboratory values is imperative to exclude other more
common hematologic disorders responsible for unexplained pur-
pura and ecchymosis. Lab values, including erythrocyte sedi-
mentation rate (ESR), bleeding time (BT), coagulation factors,
prothrombin time (PT), partial thromboplastin time (PTT), and
platelet count, are generally all negative in cases of GDS, prov-
ing there is no bleeding disorder causing the lesions and ecchy-
moses experienced by the patient. A family history of bleeding
disorders or platelet dysfunction must be noted as well.7
Diagnostic confirmation of GDS includes observation of lesion
development within 24 hours after an intradermal injection of
autologous washed erythrocytes. In most positive cases, these
1

ª 2018 The International Society of Dermatology International Journal of Dermatology 2018

2 Review GDS Review
lesions will progress to ecchymoses. An intradermal injection of
saline is often done as well to act as a control in which no
lesions should develop. Though the pathogenesis of GDS is
unclear, studies have suggested GDS involves an autosensiti-
zation to the phosphoglyceride component of the red blood cell
membrane. An atypical organization of erythrocyte phos-
phatidylserine on the cell membrane of red blood cells has also
been indicated in GDS cases. This elicits a response to the
autologous washed erythrocyte injection. Although GDS gener-
ally presents with a positive reaction to this test, there are
cases of GDS in which no reaction occurs to the injection.9
Thus, in all cases patient history and physical examination need
to be looked at closely for a correct diagnosis to be made.
Due to the rarity of this condition, there currently is no con-
sensus on optimal treatment of GDS. The typical treatment
modalities focus on the psychological component of the disorder
and include selective serotonin reuptake inhibitors (SSRIs), cor-
ticosteroids, tricyclic antidepressants (TCAs), and psychother-
apy. Treatment is typically successful when aimed at resolving
underlying psychiatric issues and supportive measures for the
dermatological manifestations. Overall, a positive correlation
between psychological improvement and resolution of symp-
toms has been observed.7,9 The goal of this study is to review
and methodically analyze the present literature to better under-
stand the clinical presentation of GDS and examine current
treatment options and their efficacy for patients affected by
GDS.
Methods
The National Library of Medicine’s PubMed database was sys-
tematically searched up to December 2017. The following
search terms were used: “Gardner Diamond Syndrome”, “GDS”,
“psychogenic purpura”, “auto-erythrocyte sensitization syn-
drome”, combined with “ecchymoses”, “psychological”, and
“treatment.” The full text of potentially relevant articles were
retrieved for review after screening titles and abstracts for pos-
sible inclusion. The articles for this review were selected based
on the following criteria: the article must be in English, only
report cases involving primary human subjects, include a diag-
nosis of GDS, and discuss treatment for each case. Articles that
did not meet inclusion criteria were excluded from review.
Results
The initial search of PubMed provided 155 articles. The titles
and abstracts were screened after which a full text of 54 articles
were chosen for review. Based on completion of the full text
review, 24 articles were excluded because of failure to meet cri-
teria. Ultimately, 30 articles were included in this literature
review, comprised of 45 patient cases of GDS. All included arti-
cles were case reports (N = 30) with the vast majority of cases
reported in the United States of America (N = 21). Following
International Journal of Dermatology 2018
Block et al.
the United States of America, India (N = 7), Turkey (N = 5),
and Canada (N = 5) were the other major contributors of case
reports.
Clinical presentation
The clinical presentation of available patient data favored a dra-
matic female predominance, with 43 female patients (96%) and
only two male patients (4%). The mean patient age was
24.3 years with ages ranging from 7 to 50 years. Patient race
and ethnicity were not reported in the majority of cases. Perti-
nent past medical history included 10 cases of menstrual irregu-
larities and three cases of hysterectomy. Menstrual problems
reported were amenorrhea, menorrhagia, and irregular menstru-
ation. Hysterectomies in the patients were due to metrorrhagia.
Sixteen of the patients (36%) reported a history of physical
trauma (N = 6) or surgery (N = 10) immediately before the
onset of GDS symptoms. A number of patients also had a past
medical history of urinary tract (N = 4) or gastrointestinal
(N = 8) problems. Urinary tract problems included pyelonephri-
tis, cystitis, and urinary incontinence. Gastrointestinal problems
included abdominal colic, gastritis, and intestinal fistula. Thirty-
two of the patient cases (71%) reported psychiatric findings
along with the symptoms presented. Of the psychiatric findings,
most individuals had a past or current diagnosis of depression
(N = 22). The other psychological disorders found through psy-
chological evaluations and history taking were anxiety (N = 7),
mixed anxiety depression (N = 2), personality disorder (N = 2),
conversion disorder (N = 2), bipolar disorder (N = 1), and
obsessive-compulsive disorder (N = 1).
In addition to psychological disorders, psychological and
physiological stressors experienced by the patient are also
linked with the development of GDS. Thirty-four patients (76%)
had stressors in their lives leading up to the occurrence of the
ecchymotic episode seen at presentation. The most common
was home life conflict (N = 15), which included marital or paren-
tal conflicts at home. Death of a family member (N = 5) and
health issues of a family member (N = 5) were also frequent
stressors found in the cases reported. Stressors such as abuse
(N = 4), abortion (N = 4), being an adopted child (N = 3), and
alcoholism (N = 3) were reported as well. Although not all
patients presenting with GDS had an underlying psychological
disorder, the cases revealed 42 patients (93%) had either a
psychiatric finding or a serious life stressor experienced before
the onset of GDS symptoms. Table 1 summarizes the pertinent
psychiatric history and catalog of life stressor triggers for
patients with GDS.2,3,7–34
All patients presented with painful ecchymoses on various
aspects of the body. The most common site of the painful
ecchymoses was the lower extremities (N = 30; 67%), which
included the knees, thighs, and feet. The upper extremities
were the second most common site (N = 20; 44%), which
included the arms, forearms, and hands. The torso, back, neck,
forehead, cheeks, and periorbital area were other, less
ª 2018 The International Society of Dermatology
Block et al. GDS Review Review 3

Table 1 Psychiatric history and life stressor events of Table 2 Clinical presentation of patients with Gardner-
patients with Gardner-Diamond syndrome Diamond syndrome (N = 45)

Diagnosis Cases (%) Ecchymoses location N (%) Cases (%)

Depression 22 (49) Lower extremities 30 (67)

Anxiety 7 (16) Upper extremities 20 (44)
Personality disorder 2 (4) Head/neck 10 (22)
Conversion disorder 2 (4) Torso 3 (7)
Mixed anxiety and depressive disorder 2 (4) Unspecified 2 (4)
Bipolar disorder 1 (2) Back 1 (2)
OCD 1 (2) Associated symptoms
None/NA 13 (29) Arthralgia/myalgia/pain 7 (16)
Home life conflicts 15 (33) Headache 6 (13)
Death of a loved one 5 (11) Nausea, abdominal paina 5 (11)
Health issues 5 (11) Fatigue, emesisa 3 (7)
Abuse 4 (9) Weakness, epistaxisa 2 (4)
Abortion 4 (9) Night sweats, malaise, diarrhea, hepatomegaly, 1 (2)
Adoption 3 (7) neuropathy, hives, tachycardia, weight loss, hot
Alcoholism 2 (4) flashes, hematuria, Raynaud’sa
Total patients 45
OCD, obsessive-compulsive disorder. Mean age (range in years) 24.3 (7–50)
Female 43 (96)
Male 2 (4)
frequently reported, locations where ecchymoses also
appeared. Typically, patients experienced intermittent episodes a
These symptoms are independently calculated and represent
of ecchymoses. These recurrent episodes occurred in patients symptoms with independent percentages.
over various durations of time ranging from 1 month to 9 years.
The mean length of recurrent episodes experienced at presen-
tation is 24.9 months. The progression of GDS in patients fol- of values, which were not diagnostic of any hematologic or
lowed a similar pattern in all cases. An episode of GDS started autoimmune disorders. Biopsies from ecchymotic lesions were
with generalized pruritus, severe pain, or a burning sensation obtained in many cases as well to aid in diagnosis and clinical
followed by edema at the area. Within hours bruises formed exclusion (N = 21). The most frequent histological finding seen
which would then progress to larger ecchymotic lesions over an with biopsy was the extravasation of erythrocytes in the dermis
average of 4–5 days. As the lesions became larger, the pain (N = 13; 62%). Other common histological findings included
and swelling diminished. Lesions were of various size ranging perivascular infiltration of inflammatory cells (N = 11; 52%) and
from 2 cm to 25 cm in diameter. Lesions often were described dermal and subcutaneous hemorrhage (N = 4; 19%). In addition
as indurated and warm patches, red in color, with some patients to lab work and biopsy, 30 cases reported utilizing an intrader-
reporting tenderness that typically regressed within a week. mal injection of autologous washed erythrocytes to establish a
Along with the common presentation in the patients for GDS, diagnosis of GDS. Of these 30 patients who received the intra-
several patients reported associated symptoms with the ecchy- dermal injection, 24 had a positive result (87%) and four had a
motic episodes. The most common associated symptoms at negative result (13%). No data regarding specificity or sensitivity
presentation were headache (N = 6; 13%), arthralgia or myalgia of this test has been determined, but it has been suggested that
(N = 7; 16%), nausea (N = 5; 11%), and abdominal pain the test has low sensitivity, making a negative result not com-
(N = 5; 11%). Other associated symptoms reported were fati- pletely reliable. In the literature, the intradermal injection of
gue (N = 3; 7%), vomiting (N = 3; 7%), weakness (N = 2; 4%), autologous washed erythrocytes appears to be the gold stan-
and epistaxis (N = 2; 4%). The clinical presentation of patients dard in the workup for GDS diagnosis.
with GDS is highlighted in Table 2.2,3,7–34
Outcomes
Workup The treatment modalities for GDS were aimed at symptomatic
Several lab tests were obtained in the reviewed cases of management and alleviation of psychological distress experi-
patients. These included ESR (N = 23), platelet count (N = 42), enced by the patient. Due to the rarity of this disorder in clinical
PT (N = 38), PTT (N = 39), BT (N = 20), ANA (N = 19), and practice, the choice of treatment varied substantially between
Coombs (N = 10). Overall, lab work was normal for a majority cases. Twenty of the cases (44%) reported involved combina-
of patients, demonstrating no underlying hematological condi- tion therapy while the other 25 cases (56%) only had one
tions or other identifiable pathology. Few cases showed abnor- modality of treatment. Because GDS treatment involves treating
malities of laboratory values with slight elevation or depression the psychological component of the patient, psychotherapy

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4 Review GDS Review Block et al.

(N = 21), SSRIs (N = 9), corticosteroids (N = 8), and TCAs
(N = 7) were the most frequently used treatment modalities.
Additional treatment options were antihistamines (N = 4), ben-
zodiazepines (N = 3), immunosuppressive drugs (N = 5), and
reassurance therapy (N = 5).
Successful treatment outcomes were reported in 34 of the
patient cases (81%). Successful outcomes are defined as
improved symptoms during episodes, disappearance of lesions,
or no recurrence of lesions at follow-up. Three cases did not
report posttreatment status of patients. However, of the eight
patient cases that did not have a beneficial outcome to treat-
ment, less than half (N = 3) involved a treatment modality direc-
ted toward treating psychological symptoms. Of the 34 patient
cases that showed improvement, 30 of them included an SSRI,
TCA, psychotherapy, or reassurance therapy (88%). The SSRIs
given for treatment were escitalopram, citalopram, and sertra-
line. Patients prescribed an SSRI for treatment of symptoms
had a 100% success rate. TCAs for treatment included desipra-
mine and amitriptyline. The success rate in which TCAs were
used in treatment was 71%. Lastly, the success rate for talk
therapy, which includes psychotherapy and reassurance ther-
apy, was 96%. Overall, when management used an SSRI,
TCA, or talk therapy, the success rate was 91%. In contrast,
when management did not use those treatment modalities, the
success rate dropped to 44%. For successful treatment of
GDS, directing the treatment at the psychological stress experi-
enced by the patient appears to be necessary. Table 3 summa-
rizes the treatment modalities utilized in GDS patients and their
corresponding success rates.2,3,7–34
Examples with successful treatment outcomes after targeting
psychological therapy included a patient case reported by Set-
tle, 1983. After being diagnosed with GDS with comorbid
depression, the patient was treated with once-a-week psy-
chotherapy. Within 3 weeks, the patient experienced depressive
symptoms and the GDS lesions appeared again. Desipramine
hydrochloride 150 mg/day was prescribed resulting in the
depressive symptoms subsiding, and, subsequently, the bruises
disappeared. The patient remained symptom-free for a 6-week
period, prompting the discontinuation of the desipramine
hydrochloride. Following treatment discontinuation, depressive
symptoms reoccurred along with the ecchymotic bruising, and
the patient was ultimately successful with initiation of amitripty-
line hydrochloride 300 mg qid. GDS lesions and depression
improved while on amitriptyline, and 10 months later, the patient
remained depression and ecchymoses free.3
In another patient case described by C € ksoy et al., a
ß elik-Go
patient diagnosed with GDS and depression was prescribed esc-
italopram 5 mg/day, which eventually increased to 10 mg/day.
Once on escitalopram depressive symptoms gradually
decreased leading to pharmacological cessation after 5 months.
Four weeks after discontinuation of escitalopram, the patient
experienced another episode of GDS, and a psychiatric evalua-
tion demonstrated subclinical depressive symptoms. The patient
was started on escitalopram once again, which was used contin-
uously for 2 years. During this 2-year period, the patient exhib-
ited no recurrent GDS episodes, and at a 12-month follow-up
after stopping escitalopram, she still remained symptom free.10
The patient case described by Uthman et al., demonstrates
the role of stressors in the development of GDS. The patient
was reported to have a 3-year history of depression due to mar-
ital problems and subsequently had been on antidepressants.
Her lesions were treated with prednisone orally over a 2-week
period. Upon receiving this treatment, the patient’s lesions grad-
ually resolved. However, the physical symptoms of GDS
recurred about once a month for 4 months. Only after the
patient got a divorce was she symptom-free for 6 months. It
appears that, although corticosteroids improved symptoms, tak-
ing away the stressor ultimately was what allowed the symp-
toms to disappear without reoccurrence.11

Table 3 Summary of treatment modalities utilized for Discussion

patients with Gardner-Diamond syndrome The clinical presentation of GDS is typically consistent with
painful ecchymotic bruises developing on lower and upper
Treatment N (%) Total patients (%) Tx success (%)
extremities of the body.1–3 GDS predominantly occurs in
Psychotherapy 21 (47) 20 (95) females, and it has been suggested in literature that estrogen
SSRIs 9 (20) 9 (100) may play a role in the overwhelming unequal gender distribu-
Corticosteroids 8 (18) 3 (38) tion. This hypothesis is supported by relevant gynecological
TCAs 7 (16) 5 (71) past medical history of some GDS patients with symptoms fol-
Immunosuppressive drugs 5 (11) 0 (0)
lowing hysterectomy, amenorrhea, irregular menses, or menor-
Reassurance 5 (11) 5 (100)
Antihistaminesa 4 (9) 2 (50) rhagia.4 In these cases, estrogen may indeed have an effect on
Benzodiazepinesa 3 (3) 3 (100) the susceptibility for the development of GDS.
Combination therapy Progression of a GDS episode initially presents with an aura
Yes 20 (44) 14 (70) of pruritus and burning or tingling sensations followed by the
No 25 (56) 23 (92)
development of bruises and later progressively larger ecchy-
motic lesions over a few days. Pain and swelling tends to dimin-
TCAs, tricyclic antidepressants; Tx, treatment; SSRIs, selective ser-
otonin reuptake inhibitors. ish as the lesions grow larger, and lesions regress over the
a
These Tx modalities were in combination with psychiatric therapy. course of a week. Along with the classic ecchymotic lesions

International Journal of Dermatology 2018 ª 2018 The International Society of Dermatology

Block et al.
seen with GDS, patients regularly report associated symptoms
of headaches, nausea, abdominal pain, arthralgia, and myal-
gia.1–3 Diagnosis is often difficult to make in these patients as
GDS is a rare disorder and typically represents a diagnosis of
exclusion. Because patients present with spontaneous purpura
and ecchymoses, differential diagnosis includes conditions such
as idiopathic thrombocytopenic purpura, factor XIII deficiency,
Henoch-Schonlein purpura, or von Willebrand disease.9 Female
patients that present with multiple ecchymoses and complaints
of pain should also be screened thoroughly for domestic vio-
lence and abuse. Only after thorough history and laboratory
workup can a correct diagnosis of GDS be made.
GDS is a condition closely correlated with psychological and
physiological stress. Patients typically have a comorbid psychi-
atric disorder or a severe stressor that triggers the initial epi-
sode of GDS. Thus, in the formal diagnosis of GDS, it is a
necessity to obtain a complete history from the patient as well
as a psychiatric evaluation. Depression is the most common
comorbid psychiatric disorder seen in GDS patients, but
patients also have been reported to suffer from anxiety, person-
ality disorder, conversion disorder, bipolar disorder, or obses-
sive-compulsive disorder.3,5,6 The lesions seen in GDS typically
develop spontaneously after a stressful event or psychiatric
12
symptoms arise. Because the link between the clinical presen-
tation of GDS and psychiatric undertones is so close, history
and psychiatric evaluation must not be overlooked in making a
correct diagnosis.
Since GDS diagnosis is largely a diagnosis of exclusion, lab-
oratory values must be obtained to exclude any hematological
disorders or autoimmune disorders. Thus, laboratory values
must be within normal ranges in GDS patients. Thorough labo-
ratory evaluation includes CBC, ESR, platelet count, BT, PT,
PTT, CRP, direct and indirect Coombs test, antinuclear anti-
body, antidouble-stranded DNA, complement levels, and
rheumatoid factor.7,13 In addition to laboratory values, the data
have shown that biopsy of the ecchymotic lesions for examina-
tion of the common histological changes seen with GDS is help-
ful in aiding formal diagnosis. Typical histological results include
perivascular infiltrate of lymphocytes or neutrophils, extravasa-
tion of erythrocytes into the dermis, and evidence of dermal and
subcutaneous hemorrhages.7,14,35 These histologic changes are
not sufficient enough to confirm a diagnosis of GDS but can
help guide the differential diagnosis in the correct direction.
However, the gold standard for diagnosis is the intradermal
injection with autologous washed erythrocytes. The vast major-
ity of patients with GDS have a positive reaction to the intrader-
mal injection in which they will develop ecchymotic lesions after
being injected with their own red blood cells. Few cases will be
nonreactive to this test, which necessitates greater emphasis
on history and physical examination to correctly diagnose the
patient with GDS.9
GDS has a good prognosis when treatment is guided
towards resolving the psychological symptoms or stress
ª 2018 The International Society of Dermatology
GDS Review Review 5
experienced by the patient.9 The most successful treatment
modalities have been found to be psychotherapy, reassurance
therapy, SSRIs, and TCAs. Oftentimes there is a combined
therapy, and it is not uncommon to add corticosteroids into the
treatment regimen for the patient.12 Other experimental treat-
ments that have been tried are immunosuppressive drugs and
benzodiazepines, but success rates were highest in cases
where the patient is given additional SSRIs or TCAs in conjunc-
tion with these therapies. It has been noted that as psychiatric
symptoms start to subside, so do the physical GDS symptoms.
Therefore, to provide patients with GDS with the best outcome,
it is recommended to aim management towards treating the
psychological component that presents alongside dermatologi-
cal physical presentation.15
In addition to directing treatment at the psychological factors
of this disorder, certain supportive treatments may also be
added to relieve the dermatological symptoms of these patients.
These symptomatic therapy options have been met with varying
outcomes but include corticosteroids, antihistamines, immuno-
suppressive drugs, and hormonal contraceptives. These treat-
ments may provide symptom relief in patients, but they have
not been shown to be effective in controlling GDS manifesta-
tions.12,36 Thus, therapy for the dermatological component may
provide symptomatic management while in combination with
disease modifying treatment for the psychological symptoms to
provide the patient with the most optimal outcome.
Questions (answers provided after
references)
1 In making a correct diagnosis of GDS, physical examination
and thorough history taking is sufficient enough, true or
false?
2 Estrogen is thought to play a role in the development of
GDS, true or false?
3 The majority of patients with GDS present with painful ecchy-
moses on the extremities of the body, true or false?
4 Data analysis showed that less than half of patients with
GDS were reported to have a current or past diagnosis of a
psychological disorder, true or false?
5 Among the treatment modalities for GDS patients, SSRIs and
talk therapy had the best success rates, true or false?
6 Being the gold standard for diagnosis of GDS, if a patient has
no reaction to an intradermal injection with autologous
washed erythrocytes, the patient does not have GDS, true or
false?
7 Without a psychological disorder, severe stressors experi-
enced by the patient can still trigger an episode of GDS in a
patient, true or false?
8 Corticosteroids and immunosuppressive drugs have been
shown to provide symptomatic relief for GDS patients, but
they have not been shown to effectively control GDS mani-
festations, true or false?
International Journal of Dermatology 2018
6 Review GDS Review
9 More than one-third of GDS patients experienced physical
trauma or surgery before the onset of symptoms seen at
clinical presentation, true or false?
10 Long-term prognosis for GDS patients is not dependent on
aiming treatment towards resolving the psychological symp-
toms or stress experienced by the patient, true or false?
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Answers
1. False; 2. True; 3. True; 4. False; 5. True; 6. False; 7. True;
8. True; 9. True; 10. False.
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